Emergency Visit Denials are frequent occurrences and are difficult to appeal and have a favorable outcome.  The denial itself could be one of several specific reasons, 1) an authorization was not obtained during the medical emergency visit, 2) a medical provider outside of the plan's network was seen and was therefore not authorized for payment or 3) the medical diagnosis does not constitute an emergency visit and therefore is not medically necessary..  

How do you combat an emergency visit denial? The following are steps you should take in appealing your denial based on the specific reason of why the claim or medical service was denied.

1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

2. Verify with your physician’s office or hospital where the services were rendered that they actually called in the authorization for the emergency visit.  If either did not, advise the health plan that it should have been their responsibility to have done so and not yours.  If the physician or hospital who provided you with medical services are participating providers of your health plan you may receive an exemption for not have obtained the authorization yourself.

3. If the medical service was a severe Emergency explain to the health plan that under the conditions you or the patient were in no condition to have notified the health plan of the emergency service and that it was done when you were physically capable of doing so.

4. If a medical provider was seen outside of your network for the emergency service explain that since it was an emergency situation, you went to the nearest facility available in order that it would not further impact your health by searching for an in-network provider.

5. A health plan is primarily looking to control costs that are not medically necessary.  Contact your physician and facility to write on your behalf a letter of medical necessity for the emergency visit and to justify that it was indeed an emergent situation.

• Appeal the denial yourself by using one of our Appeal Letters.  Our Appeal Letters have been used by actual medical providers and provide arguments embedded within the Appeal Letter to make your case to the health plan to overturn your denial.  To review available appeal letters, click here and review the List of Available Appeal Letters related to Emergency Room Denials.

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